1 PROTOCOL: Warfarin Collaborative Practice Dosing Protocol CATEGORY: Clinical Date Originated: 1/28/2015 Page 1 of 18 Last Reviewed: Owner: Director of Pharmacy Last Revised: Approved by: Pharmacy & Therapeutics Committee, Medical Staff Executive Committee Retired: Collaborative Practice Agreement for Warfarin drug management, dosing, and monitoring 1. Scope: All Pharmacists who have received, completed, and passed the internal competency certification on warfarin clinical management. Population: Adult Inpatient with orders for warfarin for specific indications detailed in this protocol. It will not include patients that are status post orthopedic surgery. Outcome: Pharmacists will independently manage daily warfarin therapy according to the guidelines detailed in this protocol 2. Collaborative Practice Agreement Under this collaborative practice agreement, University of Connecticut Health Center / John Dempsey Hospital (UCHC/JDH) Pharmacists, according to and in compliance with Section 91 of Public Act 10-7 and Connecticut General Statutes sec 20-631 “An Act Concerning Collaborative Practice Between Physicians and Pharmacists”, may design, implement, and monitor a therapeutic drug plan intended to manage oral warfarin therapy upon receipt of an order from the licensed provider to the Pharmacist. The specific services provided by the Pharmacists and the methods for providing these services are described in detail in this document. These specific services are available to all adult inpatients. 3. Purpose To establish collaboration between licensed providers and pharmacists for management of adult hospitalized inpatients receiving warfarin therapy using a standardized protocol based on current peer-reviewed literature. To maximize the therapeutic efficacy of oral warfarin therapy and to minimize the potential for adverse events.
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PROTOCOL: Warfarin Collaborative Practice Dosing Protocol ... · Warfarin should be adjusted based on current INR measurements. Prior to making a dose adjustment assess Prior to making
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PROTOCOL: Warfarin Collaborative Practice Dosing Protocol
CATEGORY: Clinical Date Originated: 1/28/2015
Page 1 of 18 Last Reviewed:
Owner: Director of Pharmacy Last Revised:
Approved by: Pharmacy & Therapeutics Committee, Medical
Staff Executive Committee Retired:
Collaborative Practice Agreement for Warfarin drug management, dosing, and monitoring
1. Scope:
All Pharmacists who have received, completed, and passed the internal competency certification on warfarin
clinical management.
Population: Adult Inpatient with orders for warfarin for specific indications detailed in this protocol. It will
not include patients that are status post orthopedic surgery.
Outcome: Pharmacists will independently manage daily warfarin therapy according to the guidelines detailed
in this protocol
2. Collaborative Practice Agreement
Under this collaborative practice agreement, University of Connecticut Health Center / John Dempsey
Hospital (UCHC/JDH) Pharmacists, according to and in compliance with Section 91 of Public Act 10-7 and
Connecticut General Statutes sec 20-631 “An Act Concerning Collaborative Practice Between Physicians
and Pharmacists”, may design, implement, and monitor a therapeutic drug plan intended to manage oral
warfarin therapy upon receipt of an order from the licensed provider to the Pharmacist.
The specific services provided by the Pharmacists and the methods for providing these services are described
in detail in this document. These specific services are available to all adult inpatients.
3. Purpose
To establish collaboration between licensed providers and pharmacists for management of adult hospitalized
inpatients receiving warfarin therapy using a standardized protocol based on current peer-reviewed literature.
To maximize the therapeutic efficacy of oral warfarin therapy and to minimize the potential for adverse
events.
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4. Procedures for warfarin Collaborative Practice Agreement
4.1. Patients initiated on warfarin while admitted to an Inpatient Care Unit
4.1.1. Pharmacists will have the ability to order a baseline PT/INR prior to initiation of warfarin therapy
regardless of enrollment in the collaborative practice protocol. A PT/INR shall be done if no lab value
within 3 days prior.
4.1.2. To initiate the protocol for inpatient, the patient’s appropriately-credentialed practitioner will select the
“Warfarin Dosed per Collaborative Practice Protocol” order in the CPOE system.
4.1.2.1. Selection of Initial Warfarin Dose along indication and target range for treatment:
As part of the “Warfarin Dosed per Collaborative Practice Protocol” order in the CPOE
system, the practitioner will select an initial dose, warfarin indication and target range.
4.1.2.2. Responsibilities of Practitioner:
Will maintain ability to order warfarin if desired, however, the practitioner will be
expected to place an order in CPOE for “Warfarin Dosed per Practitioner”
Will discontinue therapy if treatment options and/or plan of care change
For the overall anticoagulation needs of the patient including non-warfarin therapy.
If patient requires another form of anticoagulation (non-warfarin), such as unfractionated
heparin or low molecular weight heparin, the provider is responsible for ordering non-
warfarin therapy.
Relay information to the pharmacist anytime there is a concern with the pharmacist’s
management of the patient’s warfarin treatment
Upon discharge, ordering outpatient INR (international normalized ratio) and providing
prescription for warfarin
4.1.2.3. Pharmacist’s Responsibilities for “Warfarin Dosed per Collaborative
Practice Protocol”:
4.1.2.3.1. Will immediately assume the responsibility for assuring the patient’s
warfarin is dosed on a daily basis.
4.1.2.3.2. New consults will be performed daily 7:30am-5:30pm. When a new
consult is received between 5:30pm-7:30am, the pharmacist will
evaluate the first dose and if in their clinical judgment the dose is appropriate they will
verify the order and the following day, the day shift
pharmacist will complete the consult.
4.1.2.3.3. Will have the ability to order lab work as related to warfarin treatment
Pharmacist will order a PT/INR, CBC w/diff prior to initiation of warfarin
therapy, if not already obtained.
Subsequent INRs shall be ordered daily unless patient has stabilized. CBC w/diff
can be ordered every 3 days if no results are available.
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4.1.2.3.4. Determination of Warfarin Dose
Pharmacists will review and collect the following patient data from the
Netaccess/LCR system, hard-copy medical record, and/or other appropriate
UCH/JDH electronic patient databases.
List data to be collected;
o Baseline INR
o Daily INR
o CBC w/diff
o Interacting concomitant drug therapy
o Albumin
o Renal function
o Previous warfarin history
o H/H
o Platelet
This data is necessary to develop an optimized warfarin dose.
Appendix II and III nomograms are to be used for the deciding initiation and
continuation doses of warfarin therapy.
Pharmacists shall check daily warfarin dose from previous day, related lab work